Abstract
The United States has expanded health insurance coverage repeatedly without building a comparable system of protection against the costs of long-term services and supports (LTSS). Medicare excludes most LTSS, Medicaid functions as a means-tested payer of last resort, and private long-term care insurance represents a minimal and increasingly inaccessible product for families, leaving the financial risk of needing help with functional impairments to fall mainly on individuals, families, and state Medicaid programs.
This paper examines how several European countries have moved further toward treating LTSS as a shared social risk, using varied combinations of social insurance, tax financing, cash allowances and supports, and cost-sharing. While no European model offers a template for direct adoption, each illuminates recurring design trade-offs: how broadly to pool risk, how to balance home-based and institutional care, how to structure cash versus in-kind benefits, how to prevent geographic inequity, and how to sustain financing over time. Lessons from European reform suggest that durable U.S. reform requires federal risk pooling, national minimum standards, investment in home- and community-based infrastructure, alongside a formal recognition of family caregivers, and a credible, durable revenue mechanism.
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Acknowledgements and disclosures
The authors would like to thank Gopi Shah Goda for her comments on an earlier draft and Cameron Crider for fact-checking assistance. The authors would also like to thank Rasa Siniakovas for excellent editorial and publication assistance.
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